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Abstract

We report a case of papillary carcinoma of the duodenum combined with right renal
carcinoma. A 58-year-old man underwent a physical examination that revealed intrahepatic
and extrahepatic bile duct dilatation on B ultrasound. Intrahepatic bile duct dilatation
could be seen on magnetic resonance imaging (MRI), but the head of the pancreas and
distal bile duct showed no tumor signals, which led to a diagnosis of periampullary
carcinoma and right renal carcinoma. Considering the trauma of pancreaticoduodenectomy
combined with renal resection operation is greater, we carried out the laparoscopic
right renal radical resection first, and then a pylorus-preserving pancreaticoduodenectomy
was performed. However, postoperative intra-abdominal infections and bleeding occurred;
our patient improved after vascular interventional microcoil embolization for the
treatment of hemostasis. The second operation for celiac necrotic tissue elimination,
jejunal fistulization and peritoneal lavage and drainage was performed 14 days latter.
Our patient improved gradually and was discharged on the 58th postoperative day. There
has been no tumor recurrence after a follow-up of 26 months.

Keywords:

Background

Duodenal papilla carcinoma is classified as a periampullary carcinoma. Its early diagnosis
is difficult because of the lesion site. It easily leads to bile duct obstruction
because the cancer is in the ampulla; therefore the main clinical feature is progressive
deepening painless jaundice
[1-3]. There have been no previous reports of cases of duodenal papilla carcinoma combined
with right renal carcinoma. Here, we describe such a case. Our patient was found to
have intrahepatic and extrahepatic bile duct dilatation on B ultrasound without other
symptoms initially, and was then hospitalized for further examination and treatment.

Case presentation

A 58-year-old man was found to have intrahepatic and extrahepatic bile duct dilatation
on B ultrasound on 12 June 2009, and was hospitalized for further examination and
treatment on 20 June 2009. Our patient was 171 cm tall and weighed 86 kg. There was
no anemia or jaundice in the palpebral or bulbar conjunctivas. The superficial lymph
nodes were not palpable. The abdomen was flat without any palpable mass. He had had
diabetes and hypertension that had been under regular medical control for the past
20 years. Abdominal ultrasonography was carried out and a 4.3 × 5.2 cm protruding
tumor was found in the lower pole of the right kidney. The laboratory test results
showed total bilirubin was 20.6 μmol/l and direct bilirubin was 10.3 μmol/l, the results
of a magnetic resonance imaging (MRI) scan showed (1) a lesion in the lower pole of
the right kidney, (2) cysts in the left renal area and (3) abnormal signals in the
ampulla of Vater. Intrahepatic bile duct dilatation could be seen on the MRI scan,
but the head of the pancreas and distal bile duct showed no tumor signals leading
to a diagnosis of periampullary carcinoma and right renal carcinoma. Considering the
trauma of pancreaticoduodenectomy combined with renal resection operation is greater,
and laparoscopic resection of renal tumors is feasible with fast recovery, after weighing
the risks of endoscopic retrograde cholangiopancreatography (ERCP) we carried out
the laparoscopic right renal radical resection first without carrying out ERCP. After
general anesthesia, our patient was operated on via a 2 cm skin incision under the
costal margin on the right posterior axillary line; a retroperitoneal CO2 artificial pneumoperitoneum was established, the anatomical landmarks were observed
under endoscope, the right renal artery was dissected, clipped with a blood vessel
clip and cut. Then, the renal vein was dissected and cut, the adrenal gland was retained
and the ureter was cut; the right kidney was then resected. Pathological examination
results were as shown in Figure
1a. The clinical stage and TNM staging of the renal tumor was T1N0M0 and Robson stage
I. Our patient recovered well and was discharged on the ninth postoperative day. Then,
our patient presented with abdominal pain, fever, and body weight loss of about 10
kg the following month. He was hospitalized for further examination and treatment
on 31 July 2009.

ERCP showed that an infiltrative ulcerative mass was visible in the duodenal descending
part and papilla involving the lumen half cycle; the mucosa was ulcerative and the
intestinal wall was stiff. No nipple and wrinkled wall structure could be seen. We
tried to carry out nipple angiography but were not successful. Papillary carcinoma
of the duodenum was diagnosed (Figure
1b). Our patient presented fever and other symptoms of cholangitis at this time. Percutaneous
transhepatic cholangiography drainage was carried out under the guidance of computed
tomography (CT) (Figure
2a,b). Endoscopic views of the duodenum are shown in Figure
3. Postoperative anti-infection treatment (perazone sodium and sulbactam sodium) was
applied. Our patient recovered well, then 30 days later the pylorus-preserving pancreaticoduodenectomy
was carried out; the type was determined to be pancreatic duct jejunum anastomosis.
However, postoperative intra-abdominal infections occurred on the sixth day and bleeding
occurred in the peripheral arteriolar branch around the anastomosis on the eighth
day; our patient improved after vascular interventional microcoil embolization for
the treatment of hemostasis. The second operation was performed 14 days latter. A
large number of dark red blood clots were seen on abdominal cavity exploration, mainly
concentrated in the liver, gastric and pancreatic body and tail. Celiac necrotic tissues
and blood clots were eliminated. At the same time, the gastrointestinal anastomosis
had an approximately 1 cm split and bile was leaking from the biliary intestinal anastomosis,
so jejunal fistulization was performed and peritoneal lavage and drainage was carried
out repeatedly. The clinical stage and TNM staging of the pancreatic tumor was stage
1B and T2N0M0. Our patient improved gradually without undergoing chemotherapy and
was discharged on the 58th postoperative day. There has been no tumor recurrence after
a follow-up of 26 months.

Conclusion

Duodenal papilla carcinoma is a rare finding, and comprises of less than 1% of all
digestive malignant tumors. However, it is the second most common periampullary malignancy.
The first clinical symptoms are always jaundice
[4-6]. However, in this particular case, our patient had no clinical symptoms and intrahepatic
and extrahepatic bile duct dilatation was only revealed on physical examination. The
diagnosis of periampullary carcinoma and right renal carcinoma was made when our patient
was hospitalized for further examination and treatment. He had diabetes and hypertension,
kept under regular medical control for the past 20 years. This is therefore a very
rare case. Radical resection is the only curative operation method for duodenal papilla
carcinoma
[7-9]. The trauma and risk are greater if resection of the two tumors is performed at the
same time, so we carried out the laparoscopic right renal radical resection first.
Our patient recovered well. However, he presented with symptoms of cholangitis in
the following month. The pylorus-preserving pancreaticoduodenectomy was performed
after we cured the cholangitis, then postoperative intra-abdominal infections and
bleeding occurred. This may have been caused by the preoperative cholangitis or our
patient’s diabetes. We then took appropriate treatment measures. Our patient improved
gradually and was discharged on the 58th postoperative day. There has been no tumor
recurrence after a follow-up of 2 years and 2 months.

Consent

Our patient gave his written informed consent for this case report to be published.

Competing interests

The authors have no conflicts of interest to declare.

Authors’ contributions

XZ analyzed the data, and wrote the paper. ZZ interpreted the results. SWC discussed
analyses, interpretation, and presentation. JD associated data collection and their
interpretation. All authors read and approved the manuscript.